Enhancing Integrated Care for Multimorbid Patients through a Circular Care Approach

The escalating prevalence of multimorbidity within aging populations necessitates the development of coordinated healthcare strategies capable of addressing the intricate and interrelated healthcare needs of affected individuals. These strategies must actively enhance care coordination, optimize communication and collaboration among healthcare providers, ensure the seamless continuity of care across diverse settings, and promote greater patient engagement in decision-making processes. A paradigm shift from vertical single-disease management to horizontally integrated care models is necessary for meeting the complex demands posed by multimorbidity. This study aimed to create a holistic approach to the encounter with patients with multimorbidity. Methodology: The research is based on an action research design, wherein healthcare providers, patients, caregivers, and researchers actively participated in a series of four workshops. These workshops serve the dual purpose of identifying prevailing gaps in the extant healthcare system and formulating strategic interventions to address these lacunae. The proceedings of these workshops are meticulously recorded and subjected to thematic analysis. Results: Thematic analysis of the workshop deliberations reveals five salient themes: 1. In-depth Knowledge Acquisition: Emphasizing the imperative of acquiring comprehensive insights into each other's practices and routine to bolster the continuity of care across sectors. 2. Involvement of Patients and relatives: Highlighting the initiation of cross-sectoral dialogues, particularly concerning discharge planning at the hospital level, and addressing the dearth of expectations for the relatives post-hospitalization. 3. Information Accessibility and Meaningfulness: Identifying challenges associated with information exchange across sectors and underscoring the need for disseminating contextually meaningful information. Especially important that they share information they need to know and not only nice to know from the other part. 4. Cross-Sector Collaboration: Expressing the necessity for lucid cooperation and the cultivation of a cohesive culture among healthcare professionals to mitigate misunderstandings. 5. Shared Understanding of Care: Recognizing disparate perspectives between hospital and home care, underscoring the need for a mutual understanding of the care continuum. Conclusion: Based on a co-creative process involving patients, relatives and stakeholders across care sectors, a research-informed circular care approach emerges as a viable solution to enhance cross-sectoral care for multimorbid patients. This approach advocates for relationally coordinated support within a sustainable and coherent framework. The study underscores the dearth of well-established models employing a holistic approach to multimorbid patient care, underscoring the exigency for further research in this domain. Currently, we are testing the circular care approach. An ongoing study will clarify how a circular care approach can be used in integrated care. The framework of this study is a cross-sectoral video conference with patients with multimorbidity beyond their hospital admission. At ICIC24 we will share our experience and results from using a circular care approach.